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Duckworth AD, Carter TH, Chen MJ, Gardner MJ, Watts AC. Olecranon fractures : current treatment concepts. Bone Joint J 2023; 105-B:112-123. [PMID: 36722062 DOI: 10.1302/0301-620x.105b2.bjj-2022-0703.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite being one of the most common injuries around the elbow, the optimal treatment of olecranon fractures is far from established and stimulates debate among both general orthopaedic trauma surgeons and upper limb specialists. It is almost universally accepted that stable non-displaced fractures can be safely treated nonoperatively with minimal specialist input. Internal fixation is recommended for the vast majority of displaced fractures, with a range of techniques and implants to choose from. However, there is concern regarding the complication rates, largely related to symptomatic metalwork resulting in high rates of implant removal. As the number of elderly patients sustaining these injuries increases, we are becoming more aware of the issues associated with fixation in osteoporotic bone and the often fragile soft-tissue envelope in this group. Given this, there is evidence to support an increasing role for nonoperative management in this high-risk demographic group, even in those presenting with displaced and/or multifragmentary fracture patterns. This review summarizes the available literature to date, focusing predominantly on the management techniques and available implants for stable fractures of the olecranon. It also offers some insights into the potential avenues for future research, in the hope of addressing some of the pertinent questions that remain unanswered.Cite this article: Bone Joint J 2023;105-B(2):112-123.
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Affiliation(s)
- Andrew D Duckworth
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Thomas H Carter
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh and University of Edinburgh, Edinburgh, UK
| | - Michael J Chen
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Michael J Gardner
- Department of Orthopaedic Surgery, Stanford University Medical Centre, Stanford, California, USA
| | - Adam C Watts
- Upper Limb Unit, Wrightington Hospital, Wrightington, UK
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Hopf JC, Nowak TE, Mehler D, Arand C, Gruszka D, Westphal R, Rommens PM. Nailing vs. plating in comminuted proximal ulna fractures - a biomechanical analysis. BMC Musculoskelet Disord 2020; 21:616. [PMID: 32943020 PMCID: PMC7495877 DOI: 10.1186/s12891-020-03637-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 09/08/2020] [Indexed: 11/21/2022] Open
Abstract
Background Comminuted proximal ulna fractures are severe injuries with a high degree of instability. These injuries require surgical treatment, usually angular stable plating or double plating is performed. Nailing of proximal ulna fracture is described but not performed regularly. The aim of this study was to compare a newly developed, locked proximal ulna nail with an angular stable plate in an unstable fracture of the proximal ulna. We hypothesize, that locked nailing of the proximal ulna will provide non-inferior stability compared to locked plating. Methods A defect fracture distal to the coronoid was simulated in 20 sawbones. After nailing or plate osteosynthesis the constructs were tested in a servo-pneumatic testing machine under physiological joint motion (0°-90°) and cyclic loading (30 N – 300 N). Intercyclic osteotomy gap motion and plastic deformation of the constructs were analyzed using micromotion video-analysis. Results The locked nail showed lower osteotomy gap motion (0.50 ± 0.15 mm) compared to the angular stable plate (1.57 ± 0.37 mm, p < 0.001). At the anterior cortex the plastic deformation of the constructs was significantly lower for the locked nail (0.09 ± 0.17 mm vs. 0.39 ± 0.27 mm, p = 0.003). No statistically significant differences were observed at the posterior cortex for both parameters. Conclusions Nail osteosynthesis in comminuted proximal ulna fractures shows lower osteotomy gap motion and lower amount of plastic deformation compared to locking plate osteosynthesis under laboratory conditions.
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Affiliation(s)
- Johannes Christof Hopf
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Tobias Eckhard Nowak
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Dorothea Mehler
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Charlotte Arand
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Dominik Gruszka
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Ruben Westphal
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
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Hopf JC, Nowak TE, Mehler D, Arand C, Gruszka D, Rommens PM. Nailing of proximal ulna fractures: biomechanical comparison of a new locked nail with angular stable plating. Eur J Trauma Emerg Surg 2019; 47:795-802. [PMID: 31677007 DOI: 10.1007/s00068-019-01254-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/22/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Proximal ulna fractures are common injuries and frequently treated with angular stable plating. This surgical option shows good functional results. Relevant drawbacks such as large soft tissue exposure, compromised blood supply of fracture fragments and disturbing osteosynthetic material are described. The aim of this study was to compare a new locked proximal ulna nail with angular stable plating in a biomechanical testing setup for extraarticular proximal ulna fractures. METHODS Ten pairs of sawbones with a Jupiter type IIB proximal ulna fracture (OTA 2U1A3.1) were tested after osteosynthesis with the mentioned implants in a servo-pneumatic testing machine. The testing setup simulates physiological joint motion (0°-90°) under cyclic loading (30-300 N). Primary stability and loosening of both constructs were quantified using micromotion video-analysis after 608 test cycles. RESULTS The micromotion analysis showed significantly higher primary stability of the locked nail (0.29 ± 0.13 mm) compared to the angular stable plate (0.97 ± 0.30 mm, p < 0.001). Both implants showed a low amount of loosening after completion of the test cycles. The construct with the locked nail (0.08 ± 0.06 mm) showed significantly lower dislocation of the fragments measured at the anterior cortex (plate 0.24 ± 0.13 mm, p < 0.001). CONCLUSION Nailing of proximal ulna fractures shows significantly higher primary stability and lower loosening compared to angular stable plating in our testing setup.
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Affiliation(s)
- Johannes Christof Hopf
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany.
| | - Tobias Eckhard Nowak
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Dorothea Mehler
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Charlotte Arand
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Dominik Gruszka
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
| | - Pol Maria Rommens
- Department of Orthopedics and Traumatology, University Medical Center, Langenbeckstraße 1, 55131, Mainz, Germany
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Bosman WMPF, Emmink BL, Bhashyam AR, Houwert RM, Keizer J. Intramedullary screw fixation for simple displaced olecranon fractures. Eur J Trauma Emerg Surg 2019; 46:83-89. [PMID: 30879100 PMCID: PMC7026218 DOI: 10.1007/s00068-019-01114-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 03/11/2019] [Indexed: 01/11/2023]
Abstract
Purpose Olecranon fractures are common and typically require surgical fixation due to displacement generated by the pull of the triceps muscle. The most common techniques for repairing olecranon fractures are tension-band wiring or plate fixation, but these methods are associated with high rates of implant-related soft-tissue irritation. Another treatment option is fixation with an intramedullary screw, but less is known about surgical results using this strategy. Thus, the purpose of this study was to report the clinical and functional outcomes of olecranon fractures treated with an intramedullary cannulated screw. Methods We identified 15 patients (average age at index procedure 44 years, range 16–83) with a Mayo type I or IIA olecranon fracture who were treated with an intramedullary cannulated screw at a single level 2 trauma center between 2012 and 2017. The medical record was reviewed to assess radiographic union, postoperative range of motion and complications (including hardware removal). Patient-reported outcome was evaluated using the Disabilities of the Arm, Shoulder and Hand (DASH) score. Average follow-up was 22 months (range 8–36 months). Results By the 6th month post-operative visit, 14 patients had complete union of their fracture and 1 patient had an asymptomatic non-union that did not require further intervention. Average flexion was 145° (range 135–160) and the average extension lag was 11° (range 0–30). Implants were removed in 5 patients due to soft-tissue irritation. Average DASH score (± standard deviation) by final follow-up was 16 ± 10. Conclusions Fixation of simple olecranon fractures with an intramedullary screw is a safe and easy fixation method in young patients, leading to good functional and radiological results. Compared to available data, less hardware removal is necessary than with tension-band wiring or plate fixation.
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Affiliation(s)
- Willem-Maarten P F Bosman
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands.
- Department of Surgery, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
| | - Benjamin L Emmink
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
- Department of Trauma Surgery, University Medical Center, Utrecht, The Netherlands
| | - Abhiram R Bhashyam
- Department of Trauma Surgery, University Medical Center, Utrecht, The Netherlands
- Harvard Combined Orthopaedic Residency Program, Harvard University, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - R Marijn Houwert
- Department of Trauma Surgery, University Medical Center, Utrecht, The Netherlands
| | - Jort Keizer
- Department of Surgery, St Antonius Hospital, Utrecht, The Netherlands
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Abstract
Although implant removal is common after orthopedic trauma, indications for removal remain controversial. There are few data in the literature to allow evidence-based decision-making. The risk of complications from implant removal must be weighed against the possible benefits and the likelihood of improving the patient's symptoms.
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Edwards SG, Rhodes DA, Jordan TW, Sietsema DL. The Olecranon Osteotomy-Facilitated Elbow Release (OFER). J Bone Joint Surg Am 2017; 99:1859-1865. [PMID: 29088041 DOI: 10.2106/jbjs.16.00715] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Elbow contractures can cause functional limitation, and treatment can be challenging. The purpose of this article is to describe a novel technique that releases posttraumatic elbow contractures through an olecranon osteotomy and report the outcomes. METHODS Thirty-five patients with refractory posttraumatic elbow contracture who underwent an olecranon osteotomy-facilitated elbow release (OFER) procedure were included in the study. The average patient age was 39.5 years (range, 18 to 63 years), and the mean duration of follow-up was 37.2 months (range, 24 to 72 months). Preoperative and postoperative data included age, sex, cause of contracture, previous surgical procedures, active elbow range of motion, Disabilities of the Arm, Shoulder and Hand (DASH) scores, visual analog scale pain scores, and radiographs. Intraoperative tourniquet time and complications were recorded. RESULTS The mean preoperative elbow motion arc was 33° (51° to 84° of flexion). Postoperatively, the motion arc improved significantly (p < 0.001) to 110° (16° to 126° of flexion). The mean visual analog pain scale score improved from 6.3 preoperatively to 1.4 at the time of follow-up (p < 0.001). The mean DASH score improved from 57.5 preoperatively to 10.9 postoperatively (p < 0.001). The maximal improvement in the motion arc occurred at a mean of 8.7 weeks. There was 1 postoperative ulnar neurapraxia that resolved spontaneously. The intraoperative tourniquet time averaged 27 minutes (range, 18 to 45 minutes). The average time until radiographic evidence of union of the olecranon osteotomy site was 6.6 weeks (range, 5.7 to 7.7 weeks). CONCLUSIONS The OFER is a safe and effective means of treating posttraumatic elbow contractures, and is an alternative to traditional open or arthroscopic techniques. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Scott G Edwards
- 1The CORE Institute, Phoenix, Arizona 2Department of Orthopaedic Surgery and Rehabilitation, University of Nebraska Medical Center, Omaha, Nebraska 3Scranton Orthopaedic Specialists, Dickson City, Pennsylvania
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Abstract
Some types of implants, such as plates, screws, wires, and nails, have been used for open reduction and internal fixation of olecranon fractures. A ≥ 10 cm longitudinal incision is used for open reduction and internal fixation of olecranon fractures. According to previous studies, tension band wiring is a popular method that gives good results. However, back out of the wires after the surgery is one of the main postoperative complications. Moreover, if the Kirschner wires are inserted through the anterior ulnar cortex, they may impinge on the radial neck, supinator muscle, or biceps tendon. Herein, we describe the minimally invasive tension band wiring technique using Ring-Pin. This technique can be performed through a 2 cm incision. Small skin incisions are advantageous from an esthetic viewpoint. Ring-Pin was fixed by using a dedicated cable wire that does not back out unless the cable wire breaks or slips out of the dedicated metallic clamp. As the pins are placed in intramedullary canal, this technique does not lead to postoperative complications that may occur after transcortical fixation by conventional tension band wiring. Minimally invasive tension band wiring is one of the useful options for the treatment of olecranon fractures with some advantages.
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Nowak TE, Burkhart KJ, Andres T, Dietz SO, Klitscher D, Mueller LP, Rommens PM. Locking-plate osteosynthesis versus intramedullary nailing for fixation of olecranon fractures: a biomechanical study. INTERNATIONAL ORTHOPAEDICS 2013; 37:899-903. [PMID: 23508868 DOI: 10.1007/s00264-013-1854-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 02/23/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Intramedullary nailing and locked plating for fixation of olecranon fractures has recently gained popularity. However, these two new technologies have not been compared for their biomechanical efficacy. The aim of this study was to evaluate the biomechanical stability of two newly designed fracture fixation devices for treating olecranon fractures during dynamic continuous loading: the ION intramedullary locking nail and the LCP precontoured locking compression plate. METHODS Simulated oblique olecranon fractures were created in eight pairs of fresh-frozen cadaver ulnae and stabilised using either the LCP or ION. Specimens were then subjected to continuous dynamic loading (from 25 to 200 N), with a continuous angle alteration between 0° and 90° of flexion, to perform a matched-pairs comparison. Significant differences in the distance between markers surrounding the fracture gap was determined using the Wilcoxon test after four and 300 loading cycles. RESULTS The ION resulted in significantly less displacement in the fracture gap at 0° extension (P = 0.036), 45° flexion (P = 0.035) and 90° flexion (P = 0.017) after 300 cycles of continuous loading. The measured displacements were small and were probably not of clinical significance. No mechanical failure or hardware migration was seen with either fixation technique. CONCLUSION This study shows significantly less micromotion for the ION than for the LCP in treating oblique olecranon fractures after 300 cycles of dynamic loading. Both implant types could be appropriate surgical techniques for fixation of selected olecranon fractures and osteotomies.
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Affiliation(s)
- Tobias E Nowak
- Department of Trauma Surgery, Center for Musculoskeletal Surgery, Johannes Gutenberg University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
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Abstract
BACKGROUND Proximal ulnar fractures have traditionally been fixed with either tension band wiring or plate and screw fixation. These traditional techniques often irritate the surrounding soft tissues, potentially leading to subsequent secondary hardware removal surgeries. Intramedullary proximal ulnar fixation provides similar rigid fixation, however, no review yet exists to support the clinical use of currently available implants. OBJECTIVES To investigate the clinical and radiographic short-term outcomes for multiplanar locked intramedullary nails used to treat proximal ulnar fractures. METHODS A retrospective multicenter review was conducted in 28 patients with unstable olecranon fractures treated with a new multiplanar locked intramedullary nailing system (OlecraNail, Mylad Orthopedic Solutions, McLean, VA). Radiographic union was estimated, and serial clinical outcome up to one year was assessed by strength, motion, pain (visual analog scale), and a subcutaneous ulna border palpation (SCUBP) test to assess hardware prominence. RESULTS All fractures achieved union by 8 weeks. At 12 weeks postoperatively, all motion was within 10 degrees of the contralateral side in all directions. Of the 18 patients who underwent SCUBP testing, all 18 patients reported to have no pain at 12 weeks. At one-year follow-up, all patients had resumed normal activities, including work and athletics. All of the patients who underwent the SCUBP testing continued to have no pain. CONCLUSIONS Multiplanar locked intramedullary nails offer effective management for proximal ulna fractures similar to those reported with plating techniques. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Laura Wiegand
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104 USA
| | - Joseph Bernstein
- Department of Orthopaedic Surgery, Philadelphia Veterans Hospital, University of Pennsylvania, Philadelphia, PA USA
| | - Jaimo Ahn
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 2 Silverstein, Philadelphia, PA 19104 USA
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